Delayed Sleep Phase Disorder Part 2: Treatment

Kristin was late to school again, as she had been so many times before. Since she didn't go to bed until 3:00 a.m., she wasn't able to get out of bed at 6:30 a.m. for school. This time she had to meet with the principal. The message was clear: take care of this problem or you will fail and not graduate with your class. After discussing this problem with her parents, she agreed to see her pediatrician who recommended an evaluation with a behavioral sleep specialist. The diagnosis was clear. Kristin has delayed sleep phase disorder. A letter was sent to the principal asking for a temporary later start time for school while she was working on her sleep problem. This request was granted by giving her a study hall in the morning with prior approval to miss this class if necessary. This reduced her stress considerably and helped her better focus on her school work and on the sleep program.

The sleep specialist recommended immediately limiting use of the computer and sending text messages to friends to no later than 9 p.m. Not wanting to fail this school year, she reluctantly agreed. Her parents obtained a recommended bright light box that she would start using every morning upon awakening. She started taking an over the counter supplement of melatonin, although the sleep specialist noted that this is not an FDA approved treatment and over the counter supplements are not closely regulated by the government. She also kept a sleep journal, started going to bed 15 minutes earlier every few days and used a very loud alarm to get out of bed in the morning. Although it was difficult, over a period of a number weeks she was able to "reset" her circadian clock. She eventually was going to bed around 11:00 p.m. and was able to get herself up at 6:30 a.m. She still tended to sleep a bit later on the weekends but maintained a regular 11 p.m. bed time most nights of the week, including weekends. This took some ongoing effort on her part. She almost never missed her morning study hall. She finished the school year with reasonable grades and graduated with her class.

Kristin's treatment highlights a number of the techniques used to "reset" the circadian clock and end the nightmare of delayed sleep phase disorder. The techniques are described in greater detail below.

Some of these techniques, such as keeping a sleep journal, gradually going to bed earlier and not looking into bright light sources like computers late at night can be used by any one who finds that they are going to bed and getting up later and later. Other techniques such as phototherapy, oral melatonin and chronotherapy should be used under the direction of a sleep specialist or a physician familiar with these techniques. This is because careful attention must be paid to the timing of these interventions so as to not make sleep problems worse. Calculating the appropriate times requires sound knowledge of the sleep/wake cycle and circadian rhythms. In addition, phototherapy must be used with extreme caution by anyone with a history of bipolar disorder as use of the light source at an inappropriate time could contribute to the onset of a manic episode.

Delayed sleep phase disorder occurs when there is a delay in the major sleep episode relative to the desired clock time. As a result, the person has a hard time falling asleep and getting up at a normal time. Often people with this problem will use sleeping pills or alcohol to try and get to sleep sooner but this rarely works. Alcohol usually makes the problem worse. It is still unclear to what degree both genetic and environmental factors impact on the development of this disorder but both are most likely involved. People with this disorder may experience depressed mood and have great difficulty functioning at school or work. A delayed sleep phase occurs when people are habitually going to bed later and getting up later than the desired clock time. (An advanced sleep phase, often seen in the elderly, is the opposite. The bed time and rise times occur earlier in the day than is normative.) People with delayed sleep phase disorder typically go to sleep between 2:00 and 6:00 a.m. Delayed sleep phase disorder may last from months to decades, usually starts in adolescence and rarely starts after age 30. A typical goal for treatment would be to have a sleep schedule with a sleep period of 11 p.m. to 7 a.m.

Sleeping medication is sometimes used temporarily in an effort to induce sleep at a normal time. This often is not very successful and usually results in daytime grogginess. It is most helpful to people who also have some degree of insomnia.

Morning Phototherapy involves exposure to bright light upon awakening. It helps to increase morning alertness and advances the sleep phase in the evening. An inexpensive way to get exposure to bright light (depending on weather conditions, the location and season of the year) is to open the window shades or take a walk in the bright morning sun. Alternatively a specially designed bright light box may be prescribed. These boxes provide between 2,500 and 10,000 lux. Depending on the brightness level, they are used for periods of 30 min to 2 hours. Precise timing of use is critical and is related to the core body temperature minimum. The light is administered about 30 minutes earlier every other day to help gradually advance evening sleep onset. This treatment can be effective in 2 to 3 weeks when combined with evening light avoidance, but often requires ongoing treatment to maintain gains.

Evening light avoidance involves greatly reducing room lighting and light exposure in the evening. This is necessary to prevent worsening of delayed sleep onset. It may even be necessary to use protective eyewear, such as sun glasses, in the evening when driving home from work to reduce light exposure.

Ingestion of oral melatonin later in the day has the effect of advancing the onset of sleep. Proper timing is again critical and is dependent on the dim light melatonin onset which occurs about 14 hours following the habitual wake time. A reasonable estimate for the appropriate time to take melatonin for the purpose of advancing sleep onset is about 8 hours after the natural wake up time. A lower dose is recommended in order to get the clock resetting effect without creating strong drowsiness as may occur with higher doses.

Chronotherapy can be used if there is a flexible enough daytime schedule. Sleep onset is delayed 2 - 3 hours on successive days until the desired bed time is reached. Obviously, this will be difficult for anyone with a regular work or school schedule. It may be possible to do over a vacation. Once a regular bedtime is established it must be rigorously maintained. Relapse is possible and the process may need to be repeated.

Cognitive behavior therapy is useful to help people improve their sleep hygiene such as keeping a better sleep schedule, decreasing excessive caffeine use and adhering to evening light avoidance. People with delayed sleep phase may also have conditioned arousal that contributes to concomitant insomnia that may be usefully addressed by cognitive behavior therapy.

Maintenance is extremely important. Keeping a regular bedtime and morning rise time as well as continuing to have morning light exposure and avoiding evening light are critical to maintaining the hard won gains of therapy.

I'm curious if Kristin has been able to keep on this schedule, or how long she will be able to do so. I have also been diagnosed with this sleep disorder and while getting to the adjusted time was never very difficult maintaining it was, even with school. Eventually I gave up on trying to change and got my GED instead.

Your experience is not unheard of. Maintenance is the most difficult aspect of the treatment of this disorder. Relapse is a problem and some patients find it necessary to reinstitute treatment from time to time. I use composite cases in order to protect the confidentiality of patients referred to in this blog. Kristin is therefore not a real person but a composite of a number of patients I have worked with over the years. My experience has been that many patients are indeed able to change to and then maintain a more normative sleep schedule. This often takes a great deal of effort and ongoing work. Others have found it necessary to do what you have done and accommodate their life style to the disorder. I wish you the best and we are always hopeful that new treatment approaches will become available as our understanding of this disorder increases.

I believe it a great misnomer to lead anyone to believe their biology can be "reset", especially in increments. This is only a disorder within the context of modern, cultural phenomena, where individuals are expected to perform according to work schedules manufactured by the industrial revolution, in spite of their inherited biology.

The result is a second-rate quality of life in which "maintenance" and "relapse" are considered "normal" parts of treatment course, when treament itself should evolve and even be viewed for it's misleading ideals and poor results. Yet again, the cost of treatment and poor results are shouldered solely by the patients.

There is a steady, well known list if historic figures who have made major contributions to human knowledge that kept rest hours that would now be considered a feature of disorder. And, from the perspective of evolution, a range of rhythms contributed to the survival of humans and continue to contribute to the survival of other fauna.

My hope is to some day see lifestyle considerations be supported by the conventional medical institution that could very well contribute to a stronger, more diverse range of human behaviours and perhaps greater contributions by these now tortured souls mislabled with "disorder".

This is an excellent article, though I might suggest updating it to include what we've recently discovered about blue light exposure at night. Avoiding blue light at night is less onerous than avoiding all light, and this might make the process a bit more palatable to natural night owls like myself and the above respondent.

In the last 10 years, we've discovered that it is specifically blue (and, to a lesser extent, green) wavelengths of light that delay melatonin onset at night. Wavelengths in the red and amber part of the spectrum have no negative effect on melatonin production. Thus, someone with the habit of evening activity could transition from bright light in the afternoon to amber light in the evening with a bit more ease than cutting out all light exposure.

Free apps like f.lux and twilight are now available to shift screen emissions away from the blue part of the spectrum.

With all respect, it is very hard to believe that the same person (you) wrote both the article "The Nightmare Files" in the current Psychology Today and the two blog entries this fall on "Delayed Sleep Phase" and ditto Part 2.

Here on your blog, you seem willing to admit that DSPD is chronic, lasting many decades for most patients, and may be caused by genetic factors, among others. Though you suggest it is possible to "end the nightmare of delayed sleep phase disorder," you also admit that "relapse is possible", that "ongoing effort" is necessary, and that "maintenance is extremely important".

Suggesting that "light is administered about 30 minutes earlier every other day to help gradually advance evening sleep onset" is not realistic, but all in all your blog posts show some understanding of the disorder.

"The Nightmare Files," on the other hand, is full of unprofessional and insulting nonsense which perpetuates misconceptions about genuine DSPD. Seven to sixteen percent of the population does not have DSPD. Among adults, about one in 700, equally distributed between genders, does, not one in 10. Even when chronotherapy, sleep hygiene, much light in the AM and very little in the evening etc "work", they are not going to advance the phase much more than two hours and relapse is inevitable for people who really have DSPD. The disorder is not on the morningness / eveningness continuum; it is a specific disorder.

Is there any evidence showing that "Night owls are particularly vulnerable to falling into DSPD"? Or that "emotional upheaval" is associated with the beginning of it? One doesn't "fall into" or, indeed, develop DSPD. It is a condition, not a habit. And yes, it can be a life-long nightmare.

It must be embarrassing to have your name attached to the "Nightmare Files" article, which must have been heavily edited and popularized!

There's no point in attacking someone else, especially when he is trying to help others: he just helped me!

I don't have medical insurance; thank GOODNESS for the kindness of these Psychologists, Psychiatrists, and various professionals who VOLUNTEER their services FREE of charge out of the kindness of their hearts and despite the numerous other time constraints that they must have.

Maybe, instead of attacking people, you could be grateful for their kindness and thank them.

Take what is helpful, leave the rest, and take the negativity elsewhere. If you're going to disagree, at least do so respectfully and in a constructive manner.

P.S. : To the kind professionals who are providing the free, and helpful services, throughout the Psychology Today website and blogs: Thank YOU so very, very, much! You are making a difference in the lives of others!

I stumbled across PsychToday about a month ago, of all things the "Fulfillment at Any Age" blog (it's oriented towards baby boomers and... well... I'm considerably younger!

Psychology Today is totally changing my LIFE! So, I started exploring the other blogs and you have no idea how thrilled I was to run across your blog!

I've had this horrific sleep problem for years and it is seriously impairing my academics-- I totally related to your story about the young lady. I had no idea that there was an actual name for my problem. I went to a doctor twice about this in the past and all they did was throw sleeping pills at me for "insomnia" (the medication didn't work.) I kept telling them that I sleep very very well: as long as bedtime begins at 4:00-5:00 in the morning and I sleep all day!

I am printing your blog off, and I will follow the instructions to the letter! There are no words to describe the elation that I feel right now: thank you for not just telling people what delayed sleep phase is, but for the practical advice of what steps one can take to overcome this hideous problem!!!

It's really unbelievably difficult to effectively keep a proper sleep schedule. I actually completely gave up for a while, where I worked night shifts at my part-time job (which fit my sleeping schedule perfectly) and did all of my school work from 10 to 7 am in the morning during college. Now I have a full time job working 9 to 5, and after many months I still haven't got used to it. I've heard it is only a temporary condition for adolescents.. I'm still young, so here's hoping one day I become Lark!

If DSPD is not successfully treated during childhood it can become a lifelong disorder. I have never heard of an adult with DSPD being cured of it. If anyone has I'd love to hear about it. I have however experienced a worsening of the disorder and have talked to others that have as well. It is truly a nightmare for some.

I'm so fortunate to know that I'm not alone experiencing the NIGHTMARE of this disorder. Every date and time on my planned schedule causes me an unbelievable amount of anxiety. My family is constantly stressed out due to my disorder, and they're always blaming me for the problem. When I arrive late to class, or even miss it for just about the whole semester it's "of course" because I'm just a "lazy" student.

What's more, it's really hard to get a grasp on this disorder. Because society expects one to function in particular ways, I've been "one week" away from fixing my sleep for as far back as I can remember. Alas, I never do. Everything I try fails eventually. I've been reduced to living some sort of bohemian life style. I pull an all-nighter very often, but when I try to sleep early the next night, I end up waking up in the middle of the night. Worse, if I keep sleeping, I keep sleeping to late hours in the day to compensate for the all-nighter. I'm right back to where I began: in nowhere land. Lost in the wilderness of time. This is an every week thing. The amount of stress and humiliation one experiences due to this is beyond words. I keep telling myself next week is the week I fix my life - I've been saying that for the past twenty years.

I've even gotten F's in my early-time classes. Luckily, I'm really good at academics, therefore when I argue with the instructors, they give me the grade I would have gotten without attendance being taken into account: an A. Can you believe that? I've gotten doctors notes about this so that I may bump my grades from F to A, by them just not counting attendance. My heartfelt sympathy goes to the people experiencing this nightmare that must attend class to succeed. When I have gone to the doctor, they write a note that I have insomnia and prescribe pills. They don't work for long. Even Melatonin works for a bit, but if I continue using it, I must keep taking more and more dosage before bedtime. So I got off of that to have some independence, but nothing else works.

Come to think of it, two of my maternal uncles suffer from this. One is successful, but the other is considered a lazy, irresponsible, worthless man. Poor guy, we have a disorder after all. We're not just irresponsible and lazy. I've managed to stay successful because I'm in academics, but I still have appointments to make. The torture, pain, and utter humiliation by society continues...

I've never been diagnosed for this but I would bet my sleep that that's what I have. I'm crying tears of joy within my heart for reading about this, finally.

I've had something similar to this in the past, but it has been easier and faster for me to move the sleep time later and later till it is fixed than to trying to go to bed earlier. I never took any over-the-counter pills.

I've had something similar to this in the past, but it has been easier and faster for me to move the sleep time later and later till it is fixed than to try to go to bed earlier. I never took any over-the-counter pills.

yea this article makes 0 sense. it suggests by simply moving your bedtime or the classic shine light on the persons face they will wake up.

the problem with DSPD is at nighttime the person who has this wakes up. their body sees the night hours and decides thats when it should be awake. by contrast the body sees daylight and figures it must be time to sleep. so shining light on a person who sees daylight and thinks its time to sleep is counter intuitive. it also shows a gross misunderstanding of what this person is going through.

i also dont think this is a disorder so much as society castrates and condemns these people as lazy and worthless. God knows ive been called lazy to no end for this. but for me i can sleep from 4 pm to 6 AM and not feel rested at all. i can sleep 9 AM to 4 PM and feel like conquering the world.

It just doesn't make sense to me, either. This article isn't taking the person's natural circadian rhythm into account.
For example, I naturally fall asleep at 8:30 a.m.- in light. When I wake up, the light is starting to fade. It just doesn't follow that shining a light on me when I want to wake up will do the trick. If anything, it should be the opposite.
Make it light at the time you want to sleep- at night- if that's the light condition your body is used to falling asleep in -the morning.
Using light therapy can work in some people, but only if you use it to mimic that patient's natural sleep cycle.
If anything, shining a light on someone who's used to waking up in the dark could actually further hinder them.

It is full of information on treatment, current research, links to blogs of those who have successfully treated their CRD, as well as others who have not managed to treat it despite their best efforts. In addition to bright light therapy and melatonin, using blue-blocking glasses at night (scototherapy) can help reset the circadian rhythm. Sleeping pills are usually totally useless.

I've had DSPS since the age of 1 (as reported by my mother), but I didn't get officially diagnosed until the age of 36 (though I learned about DSPS 4 years prior to that). Diagnosis was a god-send, but treatment has not been as easy or effective as they sell it in this article, in doctor's offices, and in publications. YMMV. But at least having a name to the problem reduces the anxiety and stress of not being able to go to sleep or wake up at a "normal" time. I now more or less stick to my natural schedule, and feel GREAT. It's not so easy to combine this schedule with work, unfortunately.

I'm so very glad this disorder is finally getting some much-needed recognition. Most people haven't even heard of it, let alone understand it and this leaves its sufferers very much misunderstood.

My heart breaks at some of the other responses because I understand how it is to live and feel left behind in a world that runs on time opposite to yours. If anyone else who has DSPD reads this, I want to tell you something I wish someone would have told me:
You're not lazy, you're not lacking willpower, it's not your fault and most importantly, you're not alone.

As for myself, I have an extremely severe case of Delayed Sleep Phase Disorder, or DSPD. I've had it for years with little change; in fact, it's gotten worse as I've gotten older. It's caused me nearly unimaginable difficulties in having a normal life. I fall asleep near the same time everyday: 8:30 a.m., and this is with the help of powerful sleep medication. I don't wake until 4 or 5 p.m. at the earliest. This means I rarely even see sunlight, especially in the winter months.

As if the disorder in itself isn't bad enough, it took years of trying to explain that I can't "just go to sleep earlier" or "adopt a good sleep hygiene plan" to even get an accurate diagnosis. Even after I'd gotten a name for it, which was a blessing in itself as it meant I wasn't alone, I'm still shocked at how little people understand it and how unsympathetic the people I love can be. When I say I don't think I can make it to something early in the morning, I've been told countless times, "You just have to make yourself do it." As if I hadn't been trying that for years. I wish with all my heart it was that easy.
People seem to have a very hard time understanding that it's not at all like the insomnia they had once for three weeks in college or the case of sleeplessness their grandmother got, both of which were solved, of course, by making themselves get up earlier for a couple of days.
That's not what this is, and that's not how it works.

These responses of unsolicited advice are given, of course, with a slightly reproachful smile that says, "You're making this into more than it is- you're just lazy and lacking willpower." I so wish I was. I could go to a therapist, get motivated and have it solved in a month.

I've tried every treatment I can find: weeks of light therapy, innumerable home remedies, laying in bed tossing and turning for 7 or 8 hours, different sleep medications (both prescription and over-the-counter,) relaxation techniques and even multiple tries of forcing myself to stay awake for different amounts of days, then trying to sleep at a "normal" time.
All of these things, without fail, left me drowsily looking at the clock before I fell asleep. It always reads the same: 8:30 a.m.

I doubt people would react the same way if it was something they could see- after all, the disorders and disabilities that are visible can't simply be overcome with willpower.
Neither can DSPD: it is there, it's just invisible.

I know exactly what you're saying. My sleep time is 9am my wake time is 6pm. It got worse for me too as I got older. All I can do is push my sleep time later and later until it's fixed... or I can stay up all night then all day and go to bed earlier that night. It doesn't always work and I have to try again sometimes. And it never lasts long, but sometimes I can hold a normal schedule for a week or two.

You said it all, Acerbic. BTW: I have the same bedtime-- approx. 8:30 AM. I am supposed to go on retreat soon (long story), and the thought of getting up early for Mass there is obsessing me. Or do I just stay up all night, then say I don't feel well, and crash afterwards? What a way to live! I am thinking of trying to advance my sleep time (again); hard to do, because I never have 5-6 days to myself without external interruption. The last time I tried that, I became almost non-24. So I'm really not sure what to do.

Another thing that bugs me, is that doctors-- even and especially sleep doctors-- make 1:30 or 2:30 PM the last appointment of the day. Are they nuts? If I could be reasonably coherent at that hour, I wouldn't need to see a doctor to begin with!

Oh, and the light box makes my migraines worse. Not sure if it works, anyway. I try it every once in a while... but I can't do it if I'm migraining a lot. DPSD (or DSPD?) plus migraines is a real cross. No one has been able to treat me, so far. C'est la vie.

Dim light at night helps a bit, but not much. But anyway, thank you for all your comments!

I got non-24 from trying to advance my schedule and it has just made things even worse! I wasn't aware at the time that it could cause that... I was self-treating. Now I usually just push my schedule forward to waking up around 8:30 or later, then stay up all night and the next day then go to sleep early that night. It's faster but doesn't always work.

Hi there, I have always wondered what was wrong with me, until I found out about this disorder about a year ago. I have tried everything to get up before 10am, but all my life I've never been able to do it.

People don't understand what this is like. They think that because they don't have this problem and get up at 5am every morning that it doesn't exist. Or they say "it's because you don't have a job", or "you're just being lazy - go to bed earlier". That is NOT true. My past couple of jobs have had to have been afternoon or night shift.

I've tried melatonin, sleeping pills, "light therapy", "dark therapy", pulling an allnighter, even drinking at night to try and help me sleep, but I always get to sleep at 3am earliest. It has been hell for 27 years (going on 28). I can't even keep a job or social life. The worst part is when people judge, discriminate or make you feel bad about it, by not understanding or saying things like "just go to sleep earlier". But if I went to bed earlier, I'd be laying there awake for longer. It's getting to SLEEP that's the problem. Forcing myself up early doesn't make me get to sleep earlier either.

Believe me when I say this, society doesn't recognize this as a real disorder. And there is NO support for this anywhere. Family or friends were sometimes on my back to do things in the morning, even find a job. But I think they've given up on me now..

I really wish there was a treatment that worked, or some understanding. I'm not from the US, btw.

Yeah, it's been very difficult for me, too. Of course no one understands, except for a neighbor of mine who coincidentally, has the same disorder!

It doesn't matter what your age is, or what country you live in: it's a universal disorder, I believe. It may help if you get some sun-- I know that's possibly one of my problems (though it's not a cure, and if you have any sort of mood disorder, sun can actually make things worse.) I'm not saying you do: just trying to think of variables. I'd also go easy on the alcohol-- that doesn't help anything. I can't think of anything else to say, as this is a public blog. I hope you find a good sleep doctor, but then, that's easier said than done, too!

Re: jobs, it's easier if you can do self-employment, or otherwise make your own hours (say, online). Or try writing, hospital jobs, etc. Something with a night- shift. But I've found that social life is often more difficult than employment! Still, not impossible. Tell people you have a dx condition, viz., DPSD. If you repeat the label to people, it's more credible. I had problems with my local church choir, before I stuck the label on. Now people at least believe me-- even if it doesn't change anything (and no, I still can't sing in that choir, since they do everything in the morning, now; but I found another one that does everything at night, LOL!)

Thanks for mentioning the migraines. But in my case, I get them anyway-- not sure if it's a DPSD thing, or not. (Though I'm sure sleep affects them.)

BTW, yawning is often related to migraines, too.

I am going to try to advance my sleep again, soon (2 hrs. at a time)-- before going away. Does anyone know if it's better to do two days at each new time, or just one? Something I keep forgetting to ask... If anyone has a lot of experience with advancing, please let me know. Thanks.

NeedMiracle, I think how to advance a sleep pattern depends entirely on the person and also how long it's needed to last for.

In my experience, one night is better per advancement if you need to advance your sleep pattern very quickly. This method seems better for short-term applications, like if I knew I'd have to get up much earlier than usual for a couple days, because it never really sticks when it's done so quickly and I tend to be back in my "normal" sleeping pattern within a few days.
However, if you're trying to go for a longer period of time, shorter advancements over a longer time frame seems to be the way to go, at least for me and from what I've read. For instance, a 30 minute to an hour advancement every other night until you've reached your desired sleep schedule. This tends to work longer and is more gentle on the body, but obviously takes a lot more time.

I think, in the end, you'll just have to experiment to see what works best for you.

Hi, Acerbic; thanks for the ideas! I think I will have to do 2 hours either one or two nights for each step, because that's all I have time for. To do it more slowly requires major scheduling changes in my life that I just can't do, at this point. In my case, I am so "off", that even one hour per night requires 8 days; ideally, 9. I was hoping to go with two weeks (thus, two nights at each step?); I thought that doing it that way might lessen any tendency to keep going, thus developing into a "non-24" disorder. Do you or anyone have any experience with doing it this way? But thanks for your insights. I wish I had the time to go at it more slowly! Unfortunately, life interferes... : (